Fewer Complications With Robotic Surgery in Endometrial Cancer

When introduced on a nationwide basis, minimally invasive robotic surgery is associated with the performance of a greater proportion of minimally invasive procedures, as well as improved outcomes in patients with early-stage endometrial cancer, Danish investigators found.

Specifically, this change in surgical approach leads to a significantly reduced risk of severe complications in these patients.

The study, led by Siv Lykke Jørgensen, MD, of Odense University Hospital in Denmark, and colleagues, was published in JAMA Surgery.

As pointed out by the authors, minimally invasive laparoscopic surgery (MILS) for endometrial cancer, as opposed to laparotomy, reduces complications in patients. However, the MILS rate for endometrial cancer remains low.

Minimally invasive robotic surgery (MIRS) was approved for treatment for gynecologic conditions more than a decade ago, and Jørgensen and colleagues noted that the data suggests that the implementation of MIRS increases the use of minimally invasive surgery.

In Denmark, the treatment of early-stage endometrial cancer has been centralized to six national cancer centers, each of which implemented MIRS from 2008 to 2012. Here, in this population-based study, the authors wanted to see whether the nationwide introduction of MIRS decreased the risk of severe complications in women with endometrial cancer.

The study included 5,654 women with early-stage endometrial cancer who underwent surgery from January 1, 2005 to June 30, 2015. These women were divided into two groups:

• Group 1 included women who underwent surgery before the introduction of MIRS in their regions

• Group 2 included those women who underwent surgery after the introduction of MIRS

The authors found that the rate of minimally invasive surgery (MIS) — in this case, minimally invasive laparoscopic surgery (MILS) — prior to the introduction of robotically assisted surgery was just 14.1%. That rate increased to 72.2% after the introduction of robotically assisted surgery (50% MIRS and 22.2% MILS).

Of the women included in the study, 3,091 were allocated to group 1, and 2,563 to group 2. A total of 226 women in group 1 (7.3%) had severe complications compared with 160 women in group 2 (6.2%). In multivariate logistic regression analyses, women in group 1 were found to have a significantly greater risk of developing complications compared with women in group 2 (odds ratio [OR], 1.39; 95% CI, 1.11-1.74).

In group 2 — the group that underwent surgery after the introduction of MIRS — severe complications occurred in 81 of 712 women who underwent total abdominal hysterectomy (11.4%; 95% CI, 9.1%- 13.9%), 29 of 569 women who underwent MILS (5.1%; 95% CI, 3.4%- 7.2%), and 59 of 1282 women who underwent MIRS (4.6%; 95% CI, 2.9%-5.1%).

In that group, total abdominal hysterectomy was associated with increased odds of complications compared with both MILS (OR, 2.58; 95% CI, 1.80- 3.70) and MIRS (OR, 3.87; 95% CI, 2.52-5.93). However, there was no significant difference between MILS and MIRS (OR, 1.50; 95% CI, 0.99-2.27).

In an accompanying invited commentary, Jason D. Wright, MD, of Columbia University in New York City, and colleagues, wrote that the study “demonstrates that minimally invasive hysterectomy is associated with fewer complications than laparotomy and that increasing use of MIS improves surgical outcomes.”

However, the commentary stated, the question remains whether a robotically assisted surgical program is required to increase the use of minimally invasive surgery.

With that question in mind, Wright and co-authors noted that the study by Jørgensen et al. comes with several caveats, including that the study did not have a true control group, and that the results could have been confounded by the fact that endometrial cancer care was centralized into six regional cancer centers in Denmark at the time robotically assisted surgery was being introduced.

“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,” the commentary concluded. “Going forward, the use of MIS for early-stage endometrial cancer should be an important quality metric. Programs to promote access to MIS, whether laparoscopic or robotically assisted, should be a priority for women with endometrial cancer.”