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Abstract & commentary
Synopsis: Laparoscopic surgery is feasible and safe in the majority of women with early stage endometrial cancer.
Source: Eltabbakh GH, et al. Cancer 2001;91:378-387.
Eltabbakh and associates report the findings of a study conducted to assess the feasibility of laparoscopy in the treatment of women with early-stage endometrial cancer and to compare the surgical outcome, cost, and quality of life among these patients with those treated with laparotomy. In this prospective study, all women with early-stage endometrial cancer who could tolerate laparoscopic surgery were treated with laparoscopically assisted vaginal hysterectomy (LAVH), bilateral salpingo-oophorectomy (BSO), and lymphadenectomy. Women with a similar disease stage who underwent similar surgical procedures using a laparotomy constituted the control group. Both groups were compared with regard to their characteristics, surgical outcome, and cost, and were interviewed regarding their quality of life. Eighty-six of 90 women with endometrial cancer underwent LAVH. The procedure was converted to laparotomy in five patients (5.8%). Laparoscopic surgery, thus, was successful in 90% of the women. There were no significant differences noted between those who underwent LAVH and those who underwent total abdominal hysterectomy (TAH) (n = 57) with regard to patient characteristics, type of surgical procedure, preoperative and postoperative hematocrit, complications, patient recall of postoperative pain, and tumor recurrence. LAVH patients had significantly smaller body mass indices, a longer surgical time, more pelvic lymph nodes, a smaller decrease in postoperative hematocrit, received less pain medication, had a shorter hospital stay, an earlier return to full activity and work, and a higher level of satisfaction with their treatment, although their procedures had a higher cost compared with TAH patients. Eltabbakh et al concluded that the majority of women with early-stage endometrial cancer can be treated with laparoscopy with an excellent surgical outcome, shorter hospitalization, earlier recovery, and improved quality of life, but with a higher cost.
Comment by David M. Gershenson, MD
This report represents an excellent experience with laparoscopic surgery for endometrial cancer performed by a single gynecologic oncologist at a major university center. This prospective study shows that LAVH + BSO and lymphadenectomy for endometrial cancer is a safe procedure that is associated with several advantages over laparotomy. Advantages of the laparoscopic approach included less blood loss, a reduced requirement for postoperative analgesia, shorter hospital stay, earlier return to full activity and work, and a higher level of patient satisfaction. Disadvantages include a longer surgical time and higher cost. In this study, the higher cost was related to higher surgeon’s fees. LAVH is not for every woman with endometrial cancer. This study excluded women with gross cervical involvement, a uterus larger than 12 weeks’ size, severe cardiopulmonary disease precluding use of the Trendelenburg position, severe hip disease precluding use of the dorsolithotomy position, a body mass index greater than 60, and prior pelvic or abdominal radiation. Reasons for conversion to laparotomy included extrauterine spread, severe adhesions, uncontrollable bleeding, and severe endometriosis. One question left unanswered is whether the outcome or cure rate is as good with the laparoscopic approach. An ongoing randomized study of the Gynecologic Oncology Group will hopefully resolve this issue. In addition, although no patients in this study developed tumor implantation in the trocar site, there have been such reports.