Minimally Invasive Surgery in Endometrial Cancer

Recent Updates

Kemi M Doll; Anuj Suri; Paola A Gehrig

Disclosures

Expert Rev of Obstet Gynecol. 2013;8(3):271-283. 

In This Article

Abstract and Introduction

Abstract

The surgical management of endometrial cancer has been markedly changed by minimally invasive techniques. After three decades of laparoscopy, robotic surgery has built upon and expanded the population of patients able to benefit from minimally invasive techniques. Updates in the field of laparoscopy continue, including single-site surgery. The emergence and rapid uptake of robotics continues to produce favorable outcomes while at the same time, expanding minimally invasive surgery to the obese and elderly populations. Sentinel lymph node detection and single-port surgery are expanding areas that will continue to push the role of minimally invasive surgery in endometrial cancer.

Introduction

Over the last 30 years, minimally invasive surgery (MIS) for the treatment of endometrial carcinoma has evolved from experimental surgery at high-volume tertiary care centers, to the standard of care. The publication of LAP2, the Gynecologic Oncology Group (GOG)-led prospective randomized control trial of laparotomy compared with laparoscopy, confirmed the growing surgical experience and supported the equivalence of MIS to that of laparotomy for the surgical management of endometrial cancer.[1] Follow-up studies addressing quality-of-life outcomes[2] and patient-reported sexual function[3] also support the MIS approach, with improved quality of life among patients who underwent MIS and equivalent sexual function in both groups. A recent update from the LAP2 trial reported favorable recurrence and survival outcomes thereby providing further support for MIS.[4]

From the exponentially increasing trend of publications on the topic of MIS for the management of endometrial cancer, the authors can infer that the proportion of patients treated with a minimally invasive approach has grown rapidly. In 2005, the Agency for Health Research and Quality reported that only an estimated 14% of all hysterectomies performed in the USA were done laparoscopically.[5] Less than 10 years later, a number of studies on the rapid adoption and integration of robotic surgery among gynecologic oncologists have been published.[6,7] These studies report at least a doubling of the proportion of endometrial cancer patients treated with MIS at their respective institutions since the introduction of a robotic surgery platform. According to the Society of Gynecologic Oncology, consensus statement in 2012, there are an estimated 1400 robotic systems available in 950 hospitals and in 2010, over 1200 gynecologic surgeons had been trained on the robotic console.[8] Such a rapid uptake and widespread use prompted the Society of Gynecologic Oncology to issue a consensus statement regarding robotic surgery in gynecologic oncology. The task force concluded that the current evidence supports the equivalence of robotic surgery with laparoscopy for the treatment of endometrial cancer. The statement that all fellowship-training programs should offer robotic surgery in addition to laparoscopy further supports this surgical approach in the field of gynecologic oncology.[8]

In this review, the authors will briefly discuss the history of laparoscopy in endometrial cancer and the recent updates on patient outcomes. The authors will further discuss the emergence of robotic surgery and the current data on surgical experience with an emphasis on comparison of laparotomy, laparoscopy and robotics. The specific challenges associated with obese and elderly patients will be discussed, as well as new and exciting technological and clinical innovations in this rapidly changing field.

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