Surgical method
EC surgical staging including pelvic and paraaortic LND can be conducted by minimally invasive surgery (MIS) or open laparotomy(49). MIS has been associated with less complications with a reported overall rate of 7%(49). However, extent of LND was unreported in all arms of this study, a potentially significant confounder(49). The other benefits of MIS are well documented such as shorter hospital stay and faster recuperation than laparotomy(46,50), as recommended by ESMO-ESGO-ESTRO 2016 (Table 3) and further supported by a recent RCT(46). Open laparotomy now tends to be used in EC patients with increased complexity including obese patients, G3 and G4 tumours and higher uterine weight(51).
MIS is inclusive of robotic and laparoscopic surgery. Despite the safety and feasibility of robotic surgery becoming widely accepted, it represents a recent technology with reduced user experience(52). Looking at various parameters of patient outcome, there are limitations such as increased cost and operative time(51,52), a factor very much dependent on the surgeon’s experience.
Robotic surgery is found to have a significantly reduced learning curve compared to laparoscopy and improved intraoperative and major complications(50). This is however opposed by multiple studies displaying no difference in complications between the different surgical techniques(52,53). A retrospective cohort study did demonstrate however, reduced urinary tract injuries in the robotic patient group despite the same overall rate of intra- and postoperative complications(52). Despite these findings, the study did not place enough attention on long-term health parameters such as return to work, quality of life and OS(52). Comparing robotic and laparoscopic conversion to open laparotomy, there are mixed findings. Some studies find a lower rate of conversion for robotic(50,52,54) but other retrospective studies found laparoscopy to have lower rates(51) or no difference between the surgical methods(53).
Thirty-day readmissions rates between methods were similar(51,52). However, readmission rates outside of the primary hospital were unknown(51). Robotic surgery is widely associated with shorter hospital stay and blood loss(50,52,55). Reduced pain may factor into the lower hospital stay allowing patients to be mobilised faster(55). In multiple studies, the reduced blood loss was not clinically significant because blood transfusion rates were unaffected(50,52,55). Yet one of these studies suggested that the reduced blood loss could reflect decreased complications and increased ability to deal with difficult anatomy(55).
In summary due to the variations in morbidity(49), further review of minimally invasive LND surgical methods is needed.