Laparoscopic surgery in women with endometrial cancer: the learning curve

OBJECTIVE: The aim of this study was to assess the effect of increasing surgeons's experience in the laparoscopic surgery of women with endometrial cancer (EC) on the surgical outcome of these patients. STUDY DESIGN: Data were obtained from a prospectively collected database of 108 patients two oncolaparoscopic centers in Czech Republic who underwent laparoscopically assisted surgical staging (LASS) from April 1996 to March 2001. Patients were arranged in chronological order and divided into three groups, based on the date of their surgery. The three groups were compared in patient characteristics and surgical outcome using one-way analysis of variance (ANOVA) and Wilcoxon rank sum test. SETTING: Department of Obstetrics and Gynecology, Endoscopic Training Center, Baby Friendly Hospital Kladno, Czech Republic. RESULTS: The three groups were similar in patient characteristics. Operative times for laparoscopic staging with pelvic lymphadenectomy (LN) decreased significantly from mean of 156.3 min for group 1 to 142.8 min for group 3 (P < 0.05). In cases LASS with pelvic lymphadenectomy was significant increase in the number lymph nodes harvested (12.4 for group 1, 13.9 for group 2, and 15.4 for group 3, P < 0.05). In cases LASS without lymphadenectomy was not significant difference in operating time, estimated blood loss, rate of conversion to laparotomy, operative complications, and length of hospital stay among the compared groups. The number of patients who underwent para-aortic lymphadanectomy was too small (n = 22), and their distribution was asymmetrical for comparison. CONCLUSION: A learning curve is demonstrated in the LASS of women with endometrial cancer. With increasing surgeon's team experience, there is significant decrease in operative time for staging with pelvic lymph node dissection and increase in the number of pelvic lymph nodes removed. The para-aortic lymphadenectomy (PALN) was found to be more challenging than pelvic lymphadenectomy.     

Laparoscopic management of endometrial cancer in nonobese and obese women: A consecutive series

STUDY OBJECTIVE: To assess the technical feasibility and surgical outcome of a 5 mm-ports technique in a consecutive series of women with endometrial cancer laparoscopically managed. DESIGN: Prospective collaborative cohort study (Canadian Task Force classification II-2). SETTING: Two gynecologic oncology units of university hospitals. PATIENTS: A series of consecutive patients undergoing laparoscopic hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymphadenectomy for the treatment of endometrial cancer. INTERVENTIONS: A 10-mm zero-degree umbilical operative laparoscope and three 5-mm suprapubic trocars were used. The lymph nodes were removed with the use of a specimen bag through the umbilical port. Intraoperative and postoperative details and complications were prospectively collected. MEASUREMENTS AND MAIN RESULTS: A total of 101 patients were enrolled. Twenty-two (21.8%) had a body mass index (BMI) of 30 kg/m2 or higher, and nine (8.9%) were severely obese (BMI > or =35 kg/m2). One hundred procedures (99%) were carried out entirely with only three 5-mm ancillary trocars. In one patient, a 5-mm trocar was replaced with a 10-mm trocar because of a lesion of the external iliac vein requiring the placement of vascular clips. One procedure needed to be converted to laparotomy. Intraoperative complications occurred in three patients (one bladder injury and one iliac vein injury, both managed laparoscopically, and one subcutaneous emphysema). Postoperative complications occurred in 10 (10%) patients. The only complication requiring a subsequent intervention was a symptomatic pelvic lymphocyst. No difference was found in surgical outcomes between obese women and those of ideal BMI. CONCLUSION: The use of only 5-mm ancillary trocars for the laparoscopic treatment of endometrial cancer can further minimize surgical invasiveness without compromising surgical efficacy and safety in patients with high BMI as well as for women with ideal BMI.     

Laparoscopic ultrasonic operative technique in surgery of women with endometrial cancer: 2 case reports

The aim of this study was to introduce a new laparoscopic ultrasonic technique in the laparoscopy-assisted surgical staging of endometrial cancer. The entire laparoscopic phase of the laparoscopic hysterectomy and pelvic lymph node dissection was performed using a 5 mm ultrasonic scalpel and shears. Ultrasonic activated technology was easy to use and allowed the surgeon to perform laparoscopic hysterectomy and lymphadenectomy close to important pelvic structures safer than in other operative techniques. This is only a case report and a larger study to confirm the advantages of the laparoscopic operative technique in surgery of women with uterine malignancy is needed.     

Cost-effectiveness analysis of endometrial cancer prevention strategies for obese women

OBJECTIVE: It is unknown whether obese women would benefit from oral contraceptives or screening as endometrial cancer prevention strategies. We estimated the net health benefits and cost-effectiveness of these strategies in a hypothetical cohort of obese women. METHODS: A Markov decision-analytic model evaluated 4 strategies: 1) no prevention (reference strategy); 2) oral contraceptive pills (OCPs) for 5 years; 3) annual screening with endometrial biopsy from age 30; 4) biennial screening from age 30. Net health benefit was life expectancy and primary outcome was the incremental cost-effectiveness ratio. Baseline and transition probabilities were obtained from published literature and the Surveillance Epidemiology and End Results database, and costs were from the U.S. Department of Health and Human Services and Agency for Healthcare Research and Quality. Sensitivity analyses were performed for uncertainty around various measures. RESULTS: Average life expectancy for all strategies ranged from 74.52 to 74.60 years. None of the strategies had an incremental cost-effectiveness ratio less than $50,000 per year of life saved relative to the next best strategy. Endometrial cancer risk in obese women had to be 13 times greater than the general population risk before OCPs were a cost-effective intervention. CONCLUSION: Oral contraceptives and current screening methods are not cost-effective endometrial cancer prevention strategies for obese women. Risk factors such as morbid obesity and longstanding anovulation may define a subgroup at highest risk of endometrial cancer for whom OCPs may be a cost-effective strategy. Interventions that reduce endometrial cancer risk further or those with additional health benefits are needed in this population. LEVEL OF EVIDENCE: III.     

Laparoscopic surgery does not increase the positive peritoneal cytology among women with endometrial carcinoma

OBJECTIVE: The purpose of our study was to find if uterine manipulation at the time of laparoscopic hysterectomy among women with endometrial carcinoma increases the incidence of malignant cells in the peritoneal washings. MATERIAL AND METHODS: We conducted a prospective study including women with clinical stage I endometrioid endometrial carcinoma undergoing laparoscopic surgery between 07/01/2000 and 07/01/2004. Surgery on all patients was conducted by the same surgeon using the same technique and instruments. Two sets of peritoneal washings were obtained, one before and one after the insertion of the Pelosi uterine manipulator. The two sets of washings were blindly reviewed by the same cytopathologist for the presence of malignant cells. Correlation was made between the two sets of washings. RESULTS: Forty-two consecutive women (age 46-90, median: 58) were enrolled in the study. The procedure was converted to laparotomy in 3 (7.6%) patients after obtaining the two sets of washings. The preoperative tumor grades were: G1: 22 (52.4%), G2: 12 (28.6%), and G3: 8 (19.0). The incidence of positive peritoneal washings was 14.3%. All patients underwent laparoscopically assisted vaginal hysterectomy with bilateral salpingo-oophorectomy, 30 patients had bilateral pelvic lymphadenectomy, and 5 patients had bilateral pelvic and para-aortic lymphadenectomy. There was perfect agreement between the two sets of washings in all patients (100%, P < .001). No patients had positive washings after the insertion of the uterine manipulator if the washings were negative before the insertion. The surgical stages were: IA: 14 (33.3%), IB: 12 (28.6%), IC: 7 (16.7%), IIA: 1 (2.4%), IIB: 1 (2.4%), IIIA: 4 (9.5%), IIIB: 1 (2.4%), IIIC: 1 (2.4%), and IV: 1 (2.4%). Twenty-nine patients received no postoperative treatment, 2 received chemotherapy, 3 received Megace, and 9 received radiation therapy. Patients were followed-up for 7-56 months (median: 28). Two patients had tumor recurrence, and one patient died secondary to her disease. Two other patients died secondary to other causes. CONCLUSIONS: We conclude that uterine manipulation at the time of laparoscopic hysterectomy does not increase the incidence of positive peritoneal cytology among women with endometrial carcinoma.     

Total laparoscopic hysterectomy versus total abdominal hysterectomy for obese women with endometrial cancer

Obesity is common in endometrial cancer and surgery for these patients is challenging. We compared total laparoscopic hysterectomy (TLH) with total abdominal hysterectomy (TAH) with respect to feasibility (operating time, estimated blood loss, length of hospital stay, and conversion to laparotomy) and safety (perioperative morbidity and mortality) in a retrospective analysis of 78 morbidly obese patients with endometrial cancer. Analysis is based on the intention to treat. The intention to treat was TLH in 47 patients and it could be successfully completed in 42 patients (89.4%). The mean weight for all patients was 118.7 kg, with patients in the TLH group weighing more and having higher ASA scores. Mean operating time and estimated blood loss were similar in both groups. Mean postoperative hospital stay was 4.4 (+/-3.9) days in the TLH group and 7.9 (+/-3.0) days in the TAH group (P < 0.0001). Wound infections occurred in 15 of 31 patients (48.4%) in the TAH group and in 1 of 47 patients (2.1%) in the TLH group. All other morbidity, as well as patterns of recurrence and survival were similar in both groups. These data justify a prospective randomized trial comparing TLH with TAH for the treatment of endometrial cancer.     

Prevalence of endometrial cancer and hyperplasia in non-symptomatic overweight and obese women

BACKGROUND: Obesity is a public health problem and it is necessary to identify if non-symptomatic obese women must be submitted to endometrial evaluation. AIMS: To determine the prevalence of endometrial hyperplasia and cancer in non-symptomatic overweight or obese women. METHODS: A cross-sectional study was carried out in 193 women submitted to an endometrial biopsy using a Pipelle de Cornier. The findings were classified as normal, hyperplasia or cancer, and the results were compared to body mass index (BMI; kg/m(2)). For the purpose of statistical analysis, women were divided into two groups: women of reproductive age and postmenopausal women, and according to BMI as overweight or obese. RESULTS: The prevalence of endometrial cancer and hyperplasia was 1.0% and 5.8% in women of reproductive age and 3.0% and 12.1% in postmenopausal women, respectively. According to logistic regression, being in the postmenopause increased the risk of endometrial hyperplasia and cancer to 1.19 (95% confidence interval (CI): 0.36-3.90), while being postmenopausal and severely obese increased the odds ratio (OR) to 1.58 (95%CI: 0.30-8.23) and being postmenopausal and morbidly obese increased the OR to 2.72 (95%CI: 0.65-11.5). No increase in risk was found in women of reproductive age who were either overweight or obese. DISCUSSION: Our results show that non-symptomatic, severe or morbidly obese postmenopausal women have a high risk of developing endometrial hyperplasia or cancer; however, no such risk was found for women of reproductive age.     

Clinical outcome and complications of laparoscopic surgery compared with traditional surgery in women with endometrial cancer

Introduction The purpose of this study was to evaluate the feasibility, clinical outcome and complications of laparoscopic surgery in women with endometrial cancer and to compare surgical outcome and postoperative early and late complications with results of traditional laparotomy. Methods Forty women with endometrial cancer underwent laparoscopic hysterectomy, bilateral salpingo-oophorectomy and pelvic lymphadenectomy. Each patient operated by laparoscopy was matched by age, preoperative clinical stage and histology of the endometrial cancer with a patient treated by the same operation but using traditional laparotomy. Half of these patients underwent total pelvic lymphadenectomy and half had pelvic lymph node sampling. The groups were compared in clinical characteristics, surgical outcomes, recoveries and early and late postoperative complications. Results The patients in the laparoscopy group had less blood loss, more lymph nodes removed, shorter hospital stay but longer operation time than those treated by laparotomy. Only one (2.5%) laparoscopy was converted to laparotomy due to pelvic adhesions. There were no intraoperative complications in either group. Postoperative complications were more common (55.0%) in the laparotomy than in the laparoscopy group (37.5%). Only one major complication (2.5%) occurred among patients undergoing laparoscopy as compared with three (7.5%) major complications in the laparotomy group. Superficial wound infection was the most common (20%) infection in laparotomy patients while vaginal cuff cellulitis occurred in 10% of laparoscopy patients. Late (>42 days) postoperative complications were almost equally frequent (20.0 and 22.5%) in both groups. Lower extremity lymph edema or pelvic lymph cyst was found in 12.5% of all cases. As a result of surgical staging the disease of 6 women (15%) in both groups was upgraded. Conclusions Laparoscopic surgery is a viable alternative to traditional surgery in the management of endometrial cancer. The surgical outcome is similar in both cases. In laparoscopic procedures the operation time is longer but the postoperative recovery time shorter than in laparotomy. Severe complications were limited in both groups, while wound infections can be avoided using laparoscopy.     

Laparoscopic assisted vaginal hysterectomy in obese women.

Twenty-two consecutive patients weighing 100 kg or more and requiring hysterectomy were treated by laparoscopic assisted vaginal hysterectomy. The mean patient weight was 105.2 kg. In 21 patients, the indication for hysterectomy was menorrhagia (9 of these had uterine fibroids) and one patient had microinvasive carcinoma of the cervix. Mean operating time was 1 hr. 53 mins; and mean hospital stay was 4.5 days. One patient (4.5%) had intraoperative injury to the interior epigastric vessels. One patient who had anterior colporrhaphy at the same time suffered transient urinary retention which resolved after one week. There were no major or long term complications. Our experience suggests that laparoscopic assisted vaginal hysterectomy is a feasible and safe option in obese patients. The low complication rate may be due, in part, to improved access through the use of this approach.     

Laparoscopic surgery for endometrial cancer: long-term results of a multicentric study

PURPOSE OF INVESTIGATION: Surgical treatment of endometrial cancer was traditionally done by laparotomy, however the laparoscopic approach has gained wider acceptance by gynecologic surgeons.The primary aim of the study was to report the perioperative and postoperative outcomes of laparoscopic surgery in a major group of patients with endometrial cancer. The second aim was to study the long-term results of laparoscopic surgery in patients with endometrial cancer. MATERIAL AND METHOD: A prospective multicentric study was conducted at three oncolaparoscopic centres; 221 women who had undergone laparoscopic (177 women) or abdominal (44 women) hysterectomy with bilateral salpingo-oophorectomy and lymphadenectomy were included in the study. Women with stage IA, grade I did not undergo lymphadenectomy unless they had a high risk histologic tumor type. Lymph node dissection was performed in 145 women with disease greater than IA or grades other than 1. RESULTS: The mean age and weight were similar in the compared laparoscopic and open groups. Perioperative blood loss was comparable in both groups (211.2 ml vs 245.7 ml, respectively) without any significant consecutive changes in serum hemoglobin values. Although the length of operating time for the laparoscopic surgery was significantly longer than the time for the laparotomy procedure (163.3 min vs 114.7 min, p < 0.0001), the laparoscopic patients were discharged from hospital much earlier at 3.9 days (range 2-16) after the laparoscopic procedure compared with 7.3 days (range 5-16) after the abdominal procedure (p < 0.0001). The difference in surgical complications between groups was statistically insignificant (p = 0.58). Similar long-term results were noted in both groups. With a median follow-up of 33.6 months for the laparoscopy group and 45.2 months for the open group, there were no significant differences in tumor recurrence (p = 0.99] or recurrence-free survival (p = 0.86) between the two groups. CONCLUSION: The study illustrates that laparoscopically assisted surgical staging of endometrial cancer is safe as an open procedure.The laparoscopic approach may also be considered for endometrial malignancy which typically occurs in obese and elderly, high-risk women. Our analysis showed no difference with respect to recurrence or survival between the compared laparoscopic and the open group.     

Radical hysterectomy in obese and morbidly obese women with cervical cancer

OBJECTIVE: To compare intraoperative and postoperative outcomes, pathologic findings, cancer recurrence, and death rates in normal-weight, overweight, obese, and morbidly obese women undergoing radical hysterectomy and pelvic lymphadenectomy for early-stage cervical cancer. METHODS: A review of patients who underwent radical hysterectomy and pelvic lymphadenectomy for invasive cervical cancer between 1990 and 2006 was performed. On the basis of body mass index (BMI) (calculated as weight [kg]/[height (m)](2)), women were categorized as normal weight (BMI 18.5-24.9), overweight (BMI 25.0-29.9), obese (BMI 30.0-34.9), or morbidly obese (BMI at least 35.0). RESULTS: Four hundred eight women met the inclusion criteria. Of these, 155 (38%) were normal weight, 126 (31%) were overweight, 77 (19%) were obese, and 50 (12%) were morbidly obese. There were no statistically significant differences between these four groups in age, Charlson comorbidity score, smoking history, stage, histologic grade or subtype, tumor size, depth of invasion, transfusion rate, operative time, or intraoperative complications. Higher BMI was significantly correlated with higher estimated operative blood loss (P=.001). There were no statistically significant differences between the groups in pathologic findings, length of postoperative hospital stay, postoperative complications, readmission rate, or proportion of women receiving adjuvant radiotherapy. At a median follow-up time of 64 months, there were no differences between groups in rates of recurrence or death from disease. CONCLUSION: Radical hysterectomy and pelvic lymphadenectomy is feasible for obese and morbidly obese women with cervical cancer. Obesity alone should not be a contraindication to radical hysterectomy in women with cervical cancer.     

Pregnancy outcomes in women with bariatric surgery as compared with morbidly obese women

Objective: Pregnancies among morbidly obese women are associated with serious adverse maternal and neonatal outcomes. Our study objective is to evaluate the effect of bariatric surgery on obstetrical outcomes.

Methods: We carried out a retrospective cohort study using the healthcare cost and utilization project – Nationwide Inpatient Sample from 2003 to 2011 comparing outcome of births among women who had undergone bariatric surgery with births among women with morbid obesity. Logistic regression was used to estimate the adjusted effect of bariatric surgery on maternal and newborn outcomes.

Results: There were 8 475 831 births during the study period (221 580 (2.6%) in morbidly obese women and 9587 (0.1%) in women with bariatric surgery). Women with bariatric surgery were more likely to be Caucasian and ≥35 years old as compared with morbidly obese women. As compared with women with morbid obesity, women with bariatric surgery had lower rates of hypertensive disorders, premature rupture of membrane, chorioamnionitis, cesarean delivery, instrumental delivery, postpartum hemorrhage, and postpartum infection. Induction of labor, postpartum blood transfusions, venous thromboembolisms, and intrauterine fetal growth restriction were more common in the bariatric surgery group. There were no differences observed in preterm births, fetal deaths, or reported congenital anomalies.

Conclusion: In general, women who undergo bariatric surgery have improved pregnancy outcomes as compared with morbidly obese women. However, the bariatric surgery group was more likely to have venous thromboembolisms, to require a blood transfusion, to have their labor induced and to experience fetal growth restriction.     

Fertility-preserving treatment in young women with endometrial cancer

Nonsurgical fertility-preserving treatment of well-differentiated endometrial cancer with systemic progestins has been described for young women who desire to preserve their fertility. The overall response to progestin treatment in 9 retrospective studies is 79% with 79 subsequent live births. Recurrence can be expected in approximately 36-40% of conservatively treated patients who initially responded. Synchronous ovarian cancer has been reported in approximately 9%. However, amongst 162 receiving systemic, continuous treatment with progestins no death caused by cancer has been reported. We review guidelines for diagnosis, treatment and follow-up in young women undergoing conservative treatment for endometrial cancer.