Clinical research Laparoscopy and laparotomy in endometrial cancer – a meta-analysis Emilia Tupacz-Mosakowska, Anna Abacjew-Chmyłko, Dariusz Wydra Department of Gynaecology, Oncologic Gynaecology and Gynaecological Endocrinology, Corresponding author: Medical University of Gdańsk, Poland Emilia Tupacz-Mosakowska Department of Gynaecology, Submitted: 2 June 2019 Oncologic Gynaecology and Accepted: 22 May 2020 Gynaecological Endocrinology Medical University of Gdańsk Arch Med Sci 17 Smoluchowskiego St DOI: https://doi.org/10.5114/aoms/122735 80-214 Gdańsk, Poland Copyright © 2021 Termedia & Banach E-mail: [email protected] Abstract Introduction: Uterine malignancies, the vast majority of which are endome- trial cancers, constitute the most common type of gynecological neoplasms in developed countries. The primary treatment for endometrial cancer is hysterectomy and bilateral salpingoophorectomy. Women with endometrial cancer can be subjected to either total abdominal hysterectomy (TAH) or to an increasingly recommended total laparoscopic hysterectomy (TLH). We decided to verify whether published evidence supports TLH as an effective, less invasive than TAH albeit still equally radical treatment for endometrial malignancies. Material and methods: The systematic review included articles indexed in MEDLINE (PubMed) and EBSCO, published between January 1974 and January 2017. The search was based on the following keywords and combinations thereof: “laparoscopy”, “laparotomy”, “endometrial cancer”, “comparative”. Twenty-six full-text articles were included in the meta-analysis. Results: A total of 5,996 patients were eligible for the analysis, among them 2,833 (47.2%) women subjected to TLH and 3,163 (52.8%) who underwent TAH. Total laparoscopic hysterectomy is associated with shorter hospital stay, faster recovery, lesser blood loss and fewer intra- and postoperative blood transfusions, reduced pain, and a lower reoperation rate than conven- tional TAH. Conclusions: All analyzed studies demonstrated that TLH is a safe and ef- fective treatment option in endometrial cancer patients. This procedure is markedly less invasive than TAH. However, considering several contraindica- tions for laparoscopy, such as peritoneal invasion, cardiorespiratory failure, history of previous surgery and large size of the uterus, qualification for a given procedure needs to be preceded by a detailed evaluation. Key words: laparoscopy, endometrial cancer, laparotomy. Introduction Uterine malignancies, the vast majority of which are endometrial can- cers (85%), constitute the most common type of gynecological neoplasms in developed countries. Annually 189,000 new cases of endometrial can- cer are registered worldwide, and yearly mortality due to this malignancy is estimated at 45,000 [1, 2]. The incidence rate of endometrial cancer in Poland is 14.8 per 100,000 and is higher than in Western European countries (nearly 12 per 100,000). The number of newly diagnosed en- dometrial cancers increased considerably in the period 1980–2000, and this tendency is expected to continue in the near future [3, 4]. Emilia Tupacz-Mosakowska, Anna Abacjew-Chmyłko, Dariusz Wydra The primary treatment for endometrial cancer and fewer blood transfusions, prompt recovery is hysterectomy and bilateral salpingoophorec- and earlier return to normal physical activity. All tomy, accompanied, in patients with an unfavor- these criteria can be satisfied by laparoscopic able profile of prognostic factors, by pelvic and techniques, which are gaining growing populari- paraaortic lymphadenectomy. Women with endo- ty as an endometrial cancer treatment. However, metrial cancer can be subjected to either total a prerequisite for the use of those minimally inva- abdominal hysterectomy (TAH) or, as is increasing- sive techniques is adequate quality of staging and ly recommended, to total laparoscopic hysterecto- radicality of the resection, both resembling those my (TLH). achieved during conventional laparotomy. There- Endometrial cancer is most commonly diag- fore, we decided to verify whether published evi- nosed in high-risk patients – women with over- dence supports TLH as an effective, less invasive weight/obesity and multiple comorbidities, such than TAH albeit still equally radical treatment for as arterial hypertension and diabetes mellitus. endometrial malignancies. The choice of an adequate treatment method The aim of this systematic review and meta- is a key determinant of 5-year survival in cancer analysis was to compare the outcomes of TAH and patients. The decision whether to choose a giv- TLH in endometrial cancer patients. en therapeutic option is based on three groups Material and methods of factors: patient-dependent (such as general condition and comorbidities), tumor-dependent The systematic review included articles indexed (stage, histological type) and medical center-de- in MEDLINE (PubMed) and EBSCO, published be- pendent [3, 5]. Another factor that needs to be tween January 1974 and January 2017. The search considered is the improvement of patients’ quali- was based on the following keywords and com- ty of life during the peri- and postoperative period; binations thereof: ‘laparoscopy’, ‘laparotomy’, ‘en- this can be achieved by shorter hospital stay, de- dometrial cancer’, ‘comparative’. The results were creased morbidity, faster healing of the surgical limited to articles published in English. Reference wound, better control of pain and lower demand lists from all identified publications and available for postoperative analgesia, reduced blood loss review articles were also searched manually. Of 572 records initially identified, a total of 204 articles were identified after assessment of their Records identified Records identified though data base though data base titles and/or abstracts for eligibility. All these pa- (initial search criteria) (initial search criteria) pers satisfied the following criteria: (1) included PubMed (n = 434) EBSCO (n = 192) endometrial cancer patients, (2) compared wom- en subjected to laparoscopic (TLH) and laparoto- mic (TAH) resection of the uterus and regional lymph nodes, and (3) analyzed early outcomes Records after duplicates removed of the surgical treatment, such as operative time, (n = 576) blood loss, length of hospital stay, intra- and postoperative morbidity, relaparotomy rates and Records excluded conversions to laparotomy during laparoscopic (unrelated, non procedures. Eventually, 26 full-text articles were English, letter review, case reports) available for meta-analysis. Studies analyzing (n = 372) the outcomes of transcervical endometrial resec- tion under laparoscopic guidance were not includ- Records evaluated in detail ed in the analysis. However, the analysis includ- and screened (n = 204) ed studies of patients with atypical endometrial hyperplasia as this condition is a precursor lesion for endometrial cancer and may co-exist with this Full text articles assessed malignancy in 15% of cases; moreover, patients for eligibility (n = 49) with either atypical endometrial hyperplasia or Full text articles endometrial cancer present with similar clinical excluded with reasons phenotype, i.e. similar comorbidities and compa- (insufficient data) rable surgical risk. Moreover, the analysis included (n = 23) eight studies comparing conventional laparoscopy (TLH) and laparotomy (TAH) with total robotic hys- Studies included in data terectomy (TRH). analysis (meta-analysis) The meta-analysis was conducted in accor- (n = 26) dance with the Meta-analysis of Observational Figure 1. Flowchart for selecting relevant articles Studies in Epidemiology (MOOSE) statement [6]. 2 Arch Med Sci Laparoscopy and laparotomy in endometrial cancer – a meta-analysis Table I. Comparison of the number of patients and the age for particular types of surgery – laparoscopy and lapa- rotomy (p < 0.05 in bold) Authors Number of patients Age [years] of the publication TLH, n TAH, n Δ (%) TLH TAH P-value Mean SD (range) Mean SD (range) Barnett et al. [29]& 107 269 60.2 – – – – 0.94 Barwijuk and 12 – 13 62 (40–91) 62 (37–83) Jankowska [20] 7.7 Bell et al. [25] 30 40 25.0 68.4 11.9 72.3 12.5 0.03 Berretta et al. [24] 27 27 0.0 67 (44–77) 63 (49–77) 0.45 Bige et al. [34] 70 70 0.0 55.56 10.62 56.24 10.55 NS Boggess et al. [19] 81 138 41.3 62.0 10.8 64.0 12.8 0.06 Boosz et al. [26] 107 160 33.1 63.2 11.0 66.7 11.3 0.01 Chiou et al. [28] 150 129 14.0 51.4 14.2 53.6 11.3 0.73 Chu et al. [33] 70 81 13.6 55.3 (29–80) 53.4 (28–75) 0.248 Coronado et al. [30] 84 192 56.3 65.9 11.2 64.7 11.2 0.245 Corrado et al. [11] 277 177 36.1 62 (28–86) 64 (35–90) 0.08 Eisenhauer et al. [18] 25 154 83.8 57 (35–79) 60 (25–84) 0.11 Eisenkop [31] 210 246 14.6 63.6 13.6 65.2 11.3 0.248 Gao and Zhang [21]* 81 81 0.0 57.02 1.06 57.64 1.16 0.69 Jung et al. [10] 25 56 55.4 49.9 10.75 50.2 8.06 0.164 Lim et al. [23] 56 36 35.7 61.4 11.7 62.7 10.6 0.77 Lu et al. [9]R 151 121 19.9 56.6 (27–82) 57.2 (29–79) 0.11 Malzoni et al. [14]R 81 78 3.7 60 11 63 14 NS Manchana et al. [27] 47 143 67.1 54 (49–62) 59 (53–65) < 0.01 Mourits et al. [15]R 185 94 49.2 62 (40–89) 63 (39–86) – Obermair et al. [16]& R 404 349 13.6 – – – – – O’Hanlan et al. [17] 76 29 61.8 60.9 13.1 67.6 13.0 0.021 Pellegrino et al. [13] 37 37 0.0 54 – 54 – – Qviqstad and Lieng [12] 281 230 18.1 – (57–65) – (62–68) – Santi et al. [22] 120 120 0.0 62 – 63 – – Terai et al. [8] 39 93 58.1 56.6 10 56.2 11.6 0.86 TLH – total laparoscopic hysterectomy, TAH – total abdominal hysterectomy, NS – statistical difference non-significant,Δ – mathematical difference in size group.